Unit 7 Study

A nurse discusses risk factors of cholelithiasis with a client. Which risk factors will the nurse include in the teaching? Select all that apply. Changes in weight Cystic fibrosis Diabetes Obesity

All Risk factors for the development of gallstones (cholelithiasis) may include: changes in weight, obesity, cystic fibrosis, and diabetes. All of these conditions impact fat metabolism, increasing the risk of developing cholesterol gallstones. Sickle cell disease does not impact the development of gallstones.

Lab of concern for pt with GI bleed due to alcoholism

Ammonia level

Impaired liver → impaired ________ → ________

Clotting; bleeding

Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because such clients:

cannot tolerate high-glucose concentration. Explanation: Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration even with insulin coverage. Intake of coffee increases the risk for gallbladder contraction, whereas intake of high protein increases risk for hepatic encephalopathy in clients with cirrhosis. Patients with pancreatitis should not be given high-fat foods because they are difficult to digest.

Protein byproduct

Amino acids, leftover amino acids form ammonia

Pruritus in cholestasis may be related to

An elevation in plasma bile acids

A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice? a) Elevated urobilinogen in the urine b) Straw-colored urine c) Reduced hematocrit d) Clay-colored stools

Clay-colored stools CorrectExplanation: Obstructive jaundice develops when a stone obstructs the flow of bile in the common bile duct. When the flow of bile to the duodenum is blocked, the lack of bile pigments results in a clay-colored stool. In obstructive jaundice, urine tends to be dark amber (not straw-colored) as a result of soluble bilirubin in the urine. Hematocrit levels aren't affected by obstructive jaundice. Because obstructive jaundice prevents bilirubin from reaching the intestine (where it's converted to urobilinogen), the urine contains no urobilinogen.

he nurse is caring for a client with hypovolemic shock. Which of these does the nurse recognize is the liver's contribution to compensate for shock states? a. Stored blood in the liver can shift to the circulation to restore blood volume. b. The liver synthesizes ADH to retain water during periods of deficiency. c. The liver makes substances which constrict blood vessels to raise blood pressure. d. Kupffer cells are responsible for regulating blood volume and blood vessel tone.

Correct response: a. Stored blood in the liver can shift to the circulation to restore blood volume. Explanation: The liver has the ability to store approximately 500 to 1000 mL of blood which can be shifted back into the general circulation during periods of hypovolemia and shock.

A nurse is caring for a client newly diagnosed with hepatitis A. Which statement by the client indicates the need for further teaching? "How did this happen? I've been faithful my entire marriage." "I'll be very careful when preparing food for my family." "I'll wash my hands often." "I'll take all my medications as ordered."

"How did this happen? I've been faithful my entire marriage." Explanation: The client requires further teaching if he suggests that he acquired the virus through sexual contact. Hepatitis A is transmitted by the oral-fecal route or through ingested food or liquid that's contaminated with the virus. Hepatitis A is rarely transmitted through sexual contact. Clients with hepatitis A need to take every effort to avoid spreading the virus to other members of their family with precautions such as preparing food carefully, washing hands often, and taking medications as ordered.

Which is the most common report by clients with pancreatitis? -Tarry, black stools and dark urine -Increased and painful urination -Increased appetite and weight gain -Severe, radiating abdominal pain

-Severe, radiating abdominal pain Clients with pancreatitis most commonly report severe mid- to upper-abdominal pain, radiating to both sides and straight to the back. The client may describe the stools as being frothy and foul smelling, not black or tarry. The client's urine may be dark. The client will not experience increased or painful urination, increased appetite, or weight gain.

A nursing instructor is explaining the pathophysiology and clinical manifestations of pancreatitis to a group of nursing students. The instructor evaluates the teaching as effective when a student correctly identifies which symptom as that most commonly reported by clients with pancreatitis? -Tarry, black stools and dark urine -Increased and painful urination -Increased appetite and weight gain -Severe, radiating abdominal pain

-Severe, radiating abdominal pain Severe abdominal pain is the major symptom of pancreatitis that causes the client to seek medical care. The pain occurs in the midepigastrium. Abdominal pain and tenderness and back pain result from irritation and edema of the inflamed pancreas. Pain is frequently acute in onset, occurring 24 to 48 hours after a very heavy meal or alcohol ingestion; it may be diffuse and difficult to localize.

Normal portal venous pressure

5-10 mm Hg

Call MD when t-tube drainage is more than?

500 cc in 24 hr

How much mL of blood can the liver store which can be shifted back into the general circulation?

500-1,000 mL of blood

How can liver contribute to compensate for shock states?

Liver can store 500 to 1,000 mL of blood which can be shifted back into the general circulation during periods of hypovolemia and shock

Diet for patient with hepatic encephalopathy

Low protein bc it's the largest source of ammonia

Appropriate diet for patient with end stage liver failure

Low protein, low sodium

Fat soluble vitamins

A, D, E, K

S/S of liver failure

Anemia, spider angioma, thrombocytopenia (decreased platelets)

Lab of concern for pt with cholestasis

ALP

What is included in a Liver Function Test (LFT)?

ALT, AST, GGT

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client? a) Administering morphine I.V. as ordered b) Providing mouth care c) Placing the client in a semi-Fowler's position d) Maintaining nothing-by-mouth (NPO) status

Administering morphine I.V. as ordered Explanation: The nurse should address the client's pain issues first by administering morphine I.V. as ordered. Placing the client in a Semi-Fowler's position, maintaining NPO status, and providing mouth care don't take priority over addressing the client's pain issues.

A client reporting shortness of breath is admitted with a diagnosis of cirrhosis. A nursing assessment reveals an enlarged abdomen with striae, an umbilical hernia, and 4+ pitting edema of the feet and legs. What is the most important data for the nurse to monitor? Bilirubin Temperature Albumin Hemoglobin

Albumin With the movement of albumin from the serum to the peritoneal cavity, the osmotic pressure of the serum decreases. This, combined with increased portal pressure, results in movement of fluid into the peritoneal cavity. The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of ascites and edema.

Tx for patient with ascites to help correct decreases in effective arterial blood volume

Albumin infusion

A patient's physician has ordered a "liver panel" in response to the patient's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply. A) Alanine aminotransferase (ALT) B) C-reactive protein (CRP) C) Gamma-glutamyl transferase (GGT) D) Aspartate aminotransferase (AST) E) B-type natriuretic peptide (BNP)

Ans: A, C, D Feedback: Liver function testing includes GGT, ALT, and AST. CRP addresses the presence of generalized inflammation and BNP is relevant to heart failure; neither is included in a liver panel.

CH. 49 A patient with liver disease has developed jaundice; the nurse is collaborating with the patient to develop a nutritional plan. The nurse should prioritize which of the following in the patient's plan? A) Increased potassium intake B) Fluid restriction to 2 L per day C) Reduction in sodium intake D) High-protein, low-fat diet

Ans: C Feedback: Patients with ascites require a sharp reduction in sodium intake. Potassium intake should not be correspondingly increased. There is no need for fluid restriction or increased protein intake.

CH. 49 A nurse is caring for a patient with severe hemolytic jaundice. Laboratory tests show free bilirubin to be 24 mg/dL. For what complication is this patient at risk? A) Chronic jaundice B) Pigment stones in portal circulation C) Central nervous system damage D) Hepatomegaly

Ans: C Feedback: Prolonged jaundice, even if mild, predisposes to the formation of pigment stones in the gallbladder, and extremely severe jaundice (levels of free bilirubin exceeding 20 to 25 mg/dL) poses a risk for CNS damage. There are not specific risks of hepatomegaly or chronic jaundice resulting from high bilirubin.

Risk factors for development of cholelithiasis

Any condition that cannot metabolize fat or impacts fat metabolism

Cause of pain with acute panreatitis?

Autodigestion of the pancreas causes the pain + irritation and edema of inflamed pancreas

Where should the t-tube bag be?

Below the site/lower than the site

Complications of t-tube post op

Bile leak due to t-tube removal, CBD obstruction, t-tube site cellulitis

Symptom of vitamin K deficiency

Bleeding/hemorrhaging

Splanchnic circulation

Blood flow to the stomach, spleen, pancreas, intestines, and liver

What can the liver do to help during hypovolemic shock?

Can give back 500-1,000 mL of blood back into the general circulation

A client comes to the clinic and informs the nurse that he is there to see the physician for right upper abdominal discomfort, nausea, and frequent belching especially after eating a meal high in fat. What disorder do these symptoms correlate with? Hepatitis Cholelithiasis Cholecystitis Biliary colic

Cholelithiasis Explanation: Initially, with cholelithiasis clients experience belching, nausea, and right upper quadrant discomfort, with pain or cramps after high-fat meal. Symptoms become acute when a stone blocks bile flow from the gallbladder. With acute cholecystitis, clients usually are very sick with fever, vomiting, tenderness over the liver, and severe pain called biliary colic. The symptoms do not correlate with hepatitis.

Why would someone with chronic pancreatitis be diagnosed later in the disease process?

Chronic pancreatitis often goes undetected

Risk factors for developing liver cancer

Cirrhosis, cigarette smoking, metastases from another site

What intervention does the nurse anticipate providing for the patient with ascites that will help correct the decrease in effective arterial blood volume that leads to sodium retention? A. Therapeutic paracentesis B. Platelet infusions C. Diuretic therapy D. Albumin infusion

D. Albumin infusion Albumin infusions help to correct decreases in effective arterial blood volume that lead to sodium retention. The use of this colloid reduces the incidence of postparacentesis circulatory dysfunction with renal dysfunction, hyponatremia, and rapid reaccumulation of ascites associated with decreased effective arterial volume.

Which nursing assessment is most important in a client diagnosed with ascites? Assessment of the oral cavity for foul-smelling breath Auscultation of abdomen Daily measurement of weight and abdominal girth Palpation of abdomen for a fluid shift

Daily measurement of weight and abdominal girth Explanation: Measuring and recording of abdominal girth and body weight daily are essential to assess the progression of ascites and its response to treatment.

A nurse has admitted a client suspected of having acute pancreatitis. The nurse knows that mild acute pancreatitis is characterized by: a) Sepsis b) Disseminated intravascular coagulopathy c) Edema and inflammation d) Pleural effusion

Edema and inflammation Correct Explanation: Severe abdominal pain is the major symptom of pancreatitis that causes the client to seek medical care. Abdominal pain and tenderness and back pain result from irritation and edema of the inflamed pancreas

ALP level in pt with cholestasis: elevated or decreased?

Elevated

Largest source of ammonia

Enzymatic and bacterial digestion of dietary and blood proteins in the GI tract

Obstruction of bile flow interferes with absorption of what?

Fat soluble vitamins A, D, E, K

What supplementation of vitamins are needed for a patient with cholelithiasis?

Fat soluble vitamins: A, D, E, K

Which hepatitis increases risk for liver cancer

HCV

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include? Hepatitis B is transmitted primarily by the oral-fecal route. Hepatitis A is frequently spread by sexual contact. Hepatitis C increases a person's risk for liver cancer. Infection with hepatitis G is similar to hepatitis A.

Hepatitis C increases a person's risk for liver cancer. Explanation: Infection with hepatitis C increases the risk of a person developing hepatic (liver) cancer. Hepatitis A is transmitted primarily by the oral-fecal route; hepatitis B is frequently spread by sexual contact and infected blood. Hepatitis E is similar to hepatitis A whereas hepatitis G is similar to hepatitis C.

Risk factors of prolonged jaundice

Hepatitis, severe jaundice (bilirubin exceeding 20 to 25) which poses risk for CNS damage

Pancreatitis etiology

Inflammation of the pancreas due to autodigestion

T-tube purpose

Inserted in common bile duct (CBD) for external drainage of bile after surgery

What is given to pt with high ammonia level

Lactulose

A nurse is planning care for a patient with acute pancreatitis. Which of the following patient outcomes does the nurse assign as the highest priority? a) Adequate fluid and electrolyte balance b) Developing no acute complications from the pancreatitis c) Maintenance of normal respiratory function d) Maintaining satisfactory pain control

Maintenance of normal respiratory function Correct Explanation: Airway and breathing are always the priority assessment. Acute pancreatitis produces retroperitoneal edema, elevation of the diaphragm, pleural effusion, and inadequate lung ventilation. Intra-abdominal infection and labored breathing increase the body's metabolic demands, which further decreases pulmonary reserve and can lead to respiratory failure. Maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.

Pain med contraindicated in pancreatitis

Meperidine (Demerol)

Orders for pt with acute pancreatitis?

NPO to inhibit stimulation of pancreas and its secretion of enzymes

Should t-tube drainage be bloody

No

Class of drugs that reduce portal venous pressure

Non-selective beta blockers, B1 receptors

Some medications that can decrease portal pressure

Propranolol and nadolol + vasopressin and octreotide (Sandostatin)

Most common presenting symptom of cholestasis

Pruritus (itchiness)

MOA of nonselective beta blockers

Reduce portal pressure by reducing portal venous inflow via 2 mechanisms: 1. A decrease in cardiac output through B1 adrenergic blockade 2. A decrease in splanchnic blood flow through B2 adrenergic blockade

Major symptom of pancreatitis that causes the patients to seek medical care?

Severe abdominal pain

Pt with ascites should avoid/decrease what

Sodium

Decrease in effective arterial blood volume can lead to

Sodium retention

Cholestasis

Stoppage of bile flow

Ammonia, the major etiologic factor in the development of encephalopathy, inhibits neurotransmission. Increased levels of ammonia are damaging to the body. The largest source of ammonia is from: a) The digestion of dietary and blood proteins. b) Excess potassium loss subsequent to prolonged use of diuretics. c) Excessive diuresis and dehydration. d) Severe infections and high fevers.

The digestion of dietary and blood proteins. Circumstances that increase serum ammonia levels tend to aggravate or precipitate hepatic encephalopathy. The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract. Ammonia from these sources increases as a result of GI bleeding (ie, bleeding esophageal varices, chronic GI bleeding), a high-protein diet, bacterial infection, or uremia.

The physician has written the following orders for a new client admitted with pancreatitis: bed rest, nothing by mouth (NPO), and administration of total parenteral nutrition (TPN). Which does the nurse attribute as the reason for NPO status? a) To aid opening up of pancreatic duct b) To prevent the occurrence of fibrosis c) To drain the pancreatic bed d) To avoid inflammation of the pancreas

To avoid inflammation of the pancreas Explanation: Pancreatic secretion is increased by food and fluid intake and may cause inflammation of the pancreas.

A patient with bleeding esophageal varices has had pharmacologic therapy with Octreotide (Sandostatin) and endoscopic therapy with esophageal varices banding, but the patient has continued to have bleeding. What procedure that will lower portal pressure does the nurse prepare the patient for? Vasopressin (Pitressin) Balloon tamponade Transjugular intrahepatic portosystemic shunting (TIPS) Sclerotherapy

Transjugular intrahepatic portosystemic shunting (TIPS) Explanation: A TIPS procedure (see Fig. 49-8) is indicated for the treatment of an acute episode of uncontrolled variceal bleeding refractory to pharmacologic or endoscopic therapy. In 10% to 20% of patients for whom urgent band ligation or sclerotherapy and medications are not successful in eradicating bleeding, a TIPS procedure can effectively control acute variceal hemorrhage by rapidly lowering portal pressure.

T/F: Liver is a more common secondary site of metastasis than a primary cancer

True

Which of the following medications is used to decrease portal pressure, halting bleeding of esophageal varices? a) Vasopressin (Pitressin) b) Spironolactone (Aldactone) c) Cimetidine (Tagamet) d) Nitroglycerin

Vasopressin (Pitressin) Vasopressin may be the initial therapy for esophageal varices, because it constricts the splanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to prevent the side effects of vasopressin. Aldactone and Tagamet do not decrease portal hypertension.

When caring for a patient with a biliary obstruction, the nurse will anticipate administering which vitamin supplements? -Vitamin A -Vitamin D -Vitamin E -Vitamin K -Vitamin B

Vitamin A, D, E, KBiliary obstruction prevents bile from entering the small intestine and thus prevents the absorption of fat-soluble vitamins. Vitamins A, D, E, and K are all fat soluble and thus would need to be supplemented in a patient with biliary obstruction. Vitamin B is water soluble and would not be recommended for a patient with biliary obstruction.

What is given if PT level is low

Vitamin K

What is necessary for normal blood clotting

Vitamin K is necessary

The nurse is teaching an older adult client about different types of proteins that can be eaten. Which food will the nurse identify that contain dietary protein? (Select all that apply.) a. beans b. nuts c. poultry d. butter e. fish

a. beans b. nuts c. poultry e. fish Dietary proteins are obtained from animal and plant food sources, which include milk, meat, fish, poultry, eggs, soy, legumes (peas, beans, and peanuts), nuts, and components of grains. Butter is a fat and not a source of protein.

How is HAV transmitted

fecal-oral

A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should: wash her hands after touching the client. place the client in a private room. wear a mask when handling the client's bedpan. wear a gown when providing personal care for the client.

wash her hands after touching the client. Explanation: To maintain enteric precautions, the nurse must wash her hands after touching the client or potentially contaminated articles and before caring for another client. A private room is warranted only if the client has poor hygiene — for instance, if the client is unlikely to wash the hands after touching infective material or is likely to share contaminated articles with other clients. For enteric precautions, the nurse need not wear a mask and must wear a gown only if soiling from fecal matter is likely.

How does albumin affect ascites

Albumin maintains oncotic pressure in the vascular system. A decrease in oncotic pressure due to low albumin level allows fluid to leak out from the interstitial spaces into the peritoneal cavity, producing ascites

Main causes of pancreatitis

Alcohol and gallstones

Name conditions that are risk factors for cholelithiasis

Cirrhosis, diabetes, obesity, rapid and frequent changes in weight, ileal resection or disease

Name some medication that make the liver toxic?

Isoniazid (INH) usually given for tuberculosis and Phenytoin (Dilantin) given for seizures

How is HBV transmitted

blood and body fluids

How is HCV transmitted

blood and body fluids, recreational drug use

How is HDV transmitted

blood, sexual contact, only occurs in people who are infected with HBV